Chapter: One

Introduction
 2

Introduction

Whether inflicted by chance or sustained during a surgical procedure, every wound

is simply a disruption of the normal continuity of tissue (Bhaskar and Cutright 1969,
p.295). When tissue has been disrupted so severely that it cannot heal naturally
(without complications or possible disfiguration) it must be held in opposition until
the healing process provides the wound with sufficient strength to withstand stress
without mechanical support (Avery et al. 1982, p.89). The rate at which wounds
regain strength during the wound healing process must be understood as a basis
for selecting the most appropriate wound closure material.

Although the skill and technique of the surgeon is important, so is the choice of
wound closure material (Chu 1981, p.371). The purpose of these materials is to
maintain wound closure until a wound is strong enough to withstand daily tensile
forces and to enhance wound healing when the wound is most vulnerable (Giray
1995, p.44). A wound may be approximated with sutures, staples, clips, skin
closure strips, or topical adhesives.

Chu (1981, p.367) and Ogrady (1994, p.208) generally classified suture materials
which includes natural and synthetics, absorbable and nonabsorbable,
monofilament and multifilament. Natural materials are more traditional and still are
used in suturing today. Synthetics are less reactive in that the resultant
inflammatory reaction around the suture material is minimized.

Wound closure is a part of any surgical procedure. Wound care and healing
process are concepts, which are usually reliant upon sutures. The suture and non-
suture repair of the tissues has been a major concern to surgeons for over four
thousand years.

The objective of laceration repair or incision closure is to approximate the edges of

a wound for sufficient length of time so that the natural healing process may occur
(Simon et al. 1998, p.188). There are a number of well proved techniques of skin
closure using a variety of materials. That is by using braided or monofilament
materials, metal clips and adhesive tapes.
 3

Conventional skin suturing techniques do have certain disadvantages, namely

undesired trauma as the needle passing through the intact skin on either side of the
wound can push microorganisms to the deeper structures in turn increases the
incidence of wound infection (Eaton et al. 1980, p. 859),anaesthesia is required
prior to suturing and is more time consuming. It can inflict needle stick injury to
operating hand and also requires recalling the patient for suture removal (Quinn
1997, p. 1528). When tension upon the wound edges is too high, it produces
prominent cross-hatching along the scar and a poor cosmetic appearance (Eaton
1980, p. 860).

Though metal clips produce excellent cosmetic result they are to be removed within
48 to 72 hours, otherwise the local increased tension and ischemia produce ugly
and permanent cross-hatching and a poor cosmetic appearance (Ogrady et al.
1994, p.207).

Adhesive tapes designed to affect skin closure are mainly limited to small facial
wounds on the account of their size and adhesive properties (Elmasalme et al.
1995, p. 838).

From the past three decades, many new biomaterials have been discovered in the
medical field. Bio-adhesives are one among them. This material when applied on
the incised tissues possesses the ability to bind them together (Giray et al. 1997,
p.257). This group of adhesives called Cyanoacrylates were first described in 1949
by Adris (Quinn 1997, p.1527) and used clinically by Coover et al (1972, p.453) as
agents to glue skin wounds (Penoff et al. 1999, p.730). These glues polymerize on
contact with basic substances such as water or blood to form a strong bond (Burns
et al. 1998, p. 1069).

Advantages of tissue adhesives over conventional wound closure techniques

include easy to use, excellent bacteriostatic property, decreased repair time,
elimination of recall visits and comparable short and long term cosmetic outcome.
They also found to provide good tensile strength, safe with negligible histotoxicity
upon application (Burns et al. 1998, p.1070). Other advantages include the
decreased need for local anaesthesia, negligible tissue deformation and avoidance
 4

of needle stick injury. They also provide excellent waterproof wound protection,
which act as a protective dressing (Giray et al. 1997, p.257).Though tissue
adhesives have many advantages over conventional wound closure techniques,
they can be used as an alternative to sutures only in superficial small and tension
free skin incisions or lacerations (Qureshi et al. 1997, p.414).

The first glue developed was Methyl Cyanoacrylate, which was studied extensively
for its potential medical applications and was rejected due to its tissue toxicity.
Methyl alcohol, which has a short molecular chain, contributes to these
complications. Further research revealed that by changing the type of alcohol in the
compound to one with a larger molecular chain, the tissue toxicity was much
reduced. By increasing the size of the molecule it was possible to lengthen the time
taken to polymerize (Burns et al. 1998, p.1068).

N-butyl-2-cyanoacrylate is commonly available medical grade tissue adhesives,

which contains four alkyl groups in their side chain (Coover et al. 1972, p.453). The
material are free flowing liquids which can be spread easily, readily wets the
surface to which it is applied and in thin film, produces very little heat(Coover et
al.1992, p.453). It will stick virtually to any biological or synthetic material but
doesn't have sufficient tensile strength to adhere tissues under significant tension,
although it has more tensile strength compared to sutures (Penoff et al. 1999,
p.730).

Prolene (polypropylene) is a monofilament suture of more recent development. It

has extremely low tissue reactivity which is better than nylon (Parell et al. 2008,
p.488). It has slightly more memory than monofilament nylon. However, it has the
greatest tensile strength and the best resistance to infection, as shown in several
studies (Chu 1981, p.370 and Grag et al. 2004, p.155)). It is manufactured in a
clear and a blue suture, this making it easily visible. The knot security with both
Prolene and the other monofilament sutures can be improved by adding an extra
surgical throw at the time of wound closure.
 5

The purpose of this study was to compare the healing and cosmetic outcome of
head and neck surgical incisions by using Polypropylene suture and N-Butyl-2-
cyanoacrylate.
 6

Justification of the study:

Incision is a basic step for surgical procedures. Suitable closure and optimal
maintenance of the surgical area are the most important factors that affect proper
wound healing, surgical success and cosmetic outcomes.

The N-butyl-2-cyanoacrylate tissue adhesive in our country is usually not used and
the available data in our context is not available. Our study is to compare the mostly
used polypropylene suture material with this newer n-butyl-2-cyanoacrylate tissue
adhesive and serves to furnish few data that would contribute to better closure of
head and neck incision.
 7

Aim and objectives:

To compare the healing and cosmetic outcomes of surgical incisions by using

Polypropylene suture material and N-butyl-2-cyanoacrylate tissue adhesives in
head and neck skin closure.

General: To evaluate the efficacy of n-butyl-2-cyanoacrylate tissue adhesives as a

wound closure material in comparison to Polypropylene sutures.

Specific:

1. To find out the average wound closing time by Polypropylene suture

materials and N-butyl-2-cyanoacrylate tissue adhesive
2. To compare the post-operative complications of incisional wound by
Polypropylene suture materials and N-butyl-2-cyanoacrylate tissue
adhesive
3. To figure out the Initial cosmetic outcomes by Polypropylene suture
materials and N-butyl-2-cyanoacrylate tissue adhesive
 8

Review of literature
 9

Review of literature:

Discovery of Cyanoacrylates by Adris in 1949 and subsequent use of this material

in surgery by Coover et al in 1959 revolutionized non-conventional suturing
techniques. Prolene (polypropylene) is a monofilament suture of more recent
development with excellent low tissue reactivity.

The general formula of the Cyanoacrylates is CH2C (CN)-COOR and a variety of

useful 2-cyanoacrylate esters can be sterilized by varying the length of the alkyl
chain attached to reduce or eliminate tissue toxicity. Butyl 2-cyanoacrylate and
higher homologous forms appear to be closest ideal materials as they induce low
tissue reactivity and toxicity.

Surinder N. Bhaskar, Joe Frisch ((1968) used N-butyl-2-cyanoacrylate in various

minor surgical procedures like gingivectomy, mucoperiosteal flap surgeries,
biopsies, ulcers, extraction sites, and free mucosal graft. They found that N-butyl-2-
cyanoacrylatein the form of a spray has been shown to be an excellent tissue
adhesive and hemostatic agent, which is well tolerated by the tissues of oral cavity.

Mehta M.J, Shah K.H treated ten cases of mandibular fractures by using N-butyl-2-
cyanoacrylateand found that there was no mobility of the fractured bony segments
in nine cases. Toxicology study showed no significant change in the blood and
urine post-operatively. They preferred to use adhesives in treating mandibular
fractures instead of bone plates due to their case of application and bacteriostatic
property.

David P. Watson (1989) treated 50 cases of facial lacerations using N-Butyl 2-

cyanoacrylate. He noticed that gluing is quick, atraumatic with good cosmetic
results. Only some patients experienced minor discomfort from the heat of
polymerization.

In their study of comparing the effectiveness of N-butyl-2-cyanoacrylatetissue

adhesive and Dexon subcuticular sutures in 46 cases Keng TM and Bucknal TE
(1989) found that both groups of wounds healed well with no wound infection or
 10

excessive inflammation. However glued wounds showed better cosmetic results

compared to subcuticular sutures consistently.

Dean M.Touriumi, Wasim F.Raslan, Michel Friedman et al (1990) compared

histotoxicity and bone graft-cartilage binding ability of Ethyl 2-cyanoacrylate and N-
butyl-2-cyanoacrylateand found that N-butyl-2-cyanoacrylatehad minimal histotoxic
effect and good bone graft-cartilage binding ability as compared to Ethyl 2-
cyanoacrylate.

Adoni A and Anteby E (1991) used N-butyl-2-cyanoacrylatetissue adhesive and

compared with catgut sutures in twenty female patients for episiotomy repair and
observed for pain in the episiotomy site, pain while walking, sitting, sleeping, lying
down, breast-feeding, micturating and defecation and found that tissue adhesive
was superior with all these variables.

The effect of N-butyl-2-cyanoacrylatetissue adhesive on demineralized allogenic

bone matrix (DABM) implants in the abdominal wall of 10 growing Sprague-Dawley
rats were studied by Ekelund A and Nilsson OS (1991). They found that DABM with
cyanoacrylate caused an intense inflammatory process with a foreign body
reaction, abolished bone induction and new bone formation. They are the opinion
that tissue adhesives should be used with caution in the treatment of fractures since
they inhibit new bone formation.

Forseth M, O’Grady K and Toriumi D.M (1992) reviewed the status of N-butyl-2-
cyanoacrylateand fibrin tissue adhesives. They stated that N-butyl-2-
cyanoacrylatehas excellent binding strength for skin closure. However its
subcutaneous implantation can result in inflammation and foreign body giant cell
reaction. Fibrin tissue adhesive demonstrated good hemostatic properties with low
binding strengths.

Ayton JM (1993) used N-butyl-2-cyanoacrylatetissue adhesive in thirteen patients

afflicted with “polar hands” painful fissuring of fingertips. The patients informed that
the pain was reduced and their finger movements were informed. Hence they
 11

concluded that cyanoacrylate is a viable adjunct in the treatment of painful

superficial finger fissures.

The efficacy of tissue adhesive as an adjunct in wound closure in terms of pain,

complications and cost effectiveness were studied by Applebaum JS, Zalut T and
Applebaum D (1993). They concluded that tissue adhesive may be preferred as a
cost –effective method with low complication rate in the repair of lacerations.

Quinn J.V, Drzewiecki, Li MM et al (1993) compared the effectiveness of healing

using N-butyl-2-cyanoacrylateand suturing in eighty one cases of pediatric facial
lacerations and concluded that N-butyl-2-cyanoacrylatetissue adhesive is a faster,
less painful method of facial laceration repair. However the cosmetic results similar
in both cases.

Zaki I, Scerri and Millard L (1994) evaluated the effectiveness of N-butyl-2-

cyanoacrylatetissue adhesive in split-thickness skin grafts in nineteen patients with
severely damaged skin. They found that split skin grafts were healed successfully in
all patients with the complete absorption within 6 months without foreign body
reaction.

Farhan N. Elmasalme, Matbouli S.A and Zuberi M.S (1995) used N-butyl-2-
cyanoacrylatetissue adhesive in closing skin incisions of more than 3274 cases and
2650 small lacerations on scalp, face and limbs. They recommend using this tissue
adhesive due to its simplicity of application, low cost and high success rate with
only 0.83% failures.

Giray CB (1995) compared N-butyl-2-cyanoacrylatetissue adhesive with silk sutures

for closing incisions made on the back of guinea-pigs for analyzing the degree of
inflammation, giant cell reaction, fibroblastic and capillary cell activity. They found
that silk sutures caused severe inflammation, giant cell reaction and delayed
healing when compared with N-butyl 2-cyanoacrylate.

Burns TB, Simon H.K, McLario D.J et al (1996) studied the effectiveness of N-butyl-
2-cyanoacrylateon lacerations in children and concluded that the use of tissue
 12

adhesive can be used as an alternative to conventional suturing. Wounds healed

well with satisfactory cosmetic appearance. They also noticed that patients suffered
less pain with their use.

Veloudios A, Kratky V, Heath Kote J.G et al (1996) studied the advantages of the
tissue adhesive N-butyl-2-cyanoacrylateand compared it with 6-0 nylon sutures for
closing bilateral upper and lower eye lid blepharoplasty skin incisions in animals.
They observed that there was no significant difference in bond strength between
the two methods at 1,2 and 4 weeks post-operatively, but the tensile strength of the
glued incisions was significantly greater than that of the sutured incisions during 9 th
post-operative week.

Samuel P.R, Roberts A.C and Nigam A (1997) various types of head and neck
operations were performed on 33 patients. All the incisions closed by using tissue
adhesive healed primarily without any infection. They also concluded that longer the
alkyl chain of adhesive molecule lesser the histotoxicity.

The effect of tissue adhesive on skin incisions in 102 patients who underwent
general and laparoscopic abdominal surgeries was studied by Qureshi A, Drew P.J,
Duthie G.S et al (1997). The study showed that N-butyl-2-cyanoacrylatetissue
adhesive can be safely and effectively used for general abdominal wound closure.

Simon H.K (1997) conducted a study to compare the long term cosmetic outcome
of N-butyl-2-cyanoacrylatewith conventional suturing for laceration repair in
children. They concluded that the N-butyl-2-cyanoacrylateis an ideal alternative to
conventional suturing for the closure of low tension lacerations with a long term
cosmetic outcome.

Giray C.B, Atasever A, Durgun B et al (1997) performed clinical and electron

microscopic comparison of silk sutures and N-butyl-2-cyanoacrylateon human
mucosa of patients who underwent root resections of the upper incisors. The
incision lines were closed with silk sutures on one side and N-butyl-2-
cyanoacrylateon the other side of the frenum. They found that epithelialization was
better on the side treated with N-butyl-2-cyanoacrylateon third and seventh post-
 13

operative day where as more scar formation with increased local inflammation
where sutures were placed. Electron microscopic observations of both tissue
specimens revealed normal ultra-structural morphology.

Simon HK, Zempsky W.T, Burns T.B et al (1998) conducted a study to evaluate the
effects of initial wound orientation on the cosmetic outcome of facial lacerations
repaired with N-butyl-2-cyanoacrylatetissue adhesive and conventional suturing.
They concluded that initial wound orientation had a greater impact on the cosmetic
appearance for lacerations closed by suturing compared to tissue adhesive. N-
butyl-2-cyanoacrylate may be the preferred method of cutaneous closure for facial
lacerations oriented against Langer’s lines.

Osmund MH, Quinn J.V, Suteliffe T et al (1999) compared the healing and cosmetic
effects of butyl cyanoacrylate and octyl cyanoacrylate in the closure of 98 pediatric
facial lacerations. They concluded that octyl cyanoacrylate is similar to butyl
cyanoacrylate in ease of use and early and late cosmetic outcomes.
The long term effects and complications of N-butyl-2-cyanoacrylatein the closure of
1098 elective surgical incisions in pediatric patients were studied by Amiel GE,
Sukhotnik I, Kawar B et al (1999). They concluded that application of N-butyl-2-
cyanoacrylateis safe with few complications and produces excellent cosmetic
results.

Craven NM and Telfer NR (1999) studied the efficacy of N-butyl-2-

cyanoacrylatetissue adhesive and conventional suturing in securing full thickness
skin grafts in 21 patients. They concluded that N-butyl-2-cyanoacrylatetissue
adhesive is suitable for securing selected full-thickness skin grafts and timesaving
over traditional approaches.

Charters A (2000) compared Indermil (n-butyl cyanoacrylate), Liquiband (n-butyl

cyanoacrylate) and Dermaband (octyl cyanoacrylate) tissue adhesives in terms of
ease of use, pain and adequate bonding time in the closure of over 39,000
lacerations. He concluded that all tissue adhesives produced satisfactory results in
terms of wound closure and ease of use. However liquiband tissue adhesive
 14

produced the most consistent results, scoring higher in most of the categories when
compared with other tissue adhesives.

Annabelle Rajaseharan (2000) conducted 3 efficacy studies using Isoamyl 2-

cyanoacrylate. In the first study, Isoamyl 2-cyanoacrylate, N-butyl-2-
cyanoacrylateand sutures were used to close skin incisions on rats, assessing for
tensile strength, wound infection and scar. In the second study, Isoamyl 2-
cyanoacrylate was compared with N-butyl-2-cyanoacrylatefor closing rat and dog-
liver wounds. In the third study, the effects of Isoamyl 2-cyanoacrylate coated
stainless steel implants, uncoated stainless steel implants and titanium implants on
bone are compared in experimental animals. Based on all these studies, Isoamyl 2-
cyanoacrylate was concluded to be the best tissue adhesive.

Pelissier P, Casoli V, Le Bail B et al (2001) used N-butyl-2-cyanoacrylatetissue

adhesive in the closure of dorsal wounds on 15 rabbits where laceration was made
bilaterally. One side was closed with fast absorbable skin sutures and the other side
with tissue adhesive applied on both deep and superficial tissues. They found that
application of glue on the cutaneous wound edges is a fast and easy procedure that
does not delay or inhibit the healing process or its quality.

Schonauer F, Pereira J, LaRusca I et al (2001) used N-butyl-2-cyanoacrylatefor

closing superficial skin lacerations in 56 pediatric patients. They concluded that it
can be safely and effectively used for superficial lacerations in children without
wound dehiscence or infection.

Ozturan O, Miman M.C, Aktas D et al (2001) conducted a study in 101 patients

undergoing open technique rhinoplastic surgery to assess whether tissue adhesives
are used inspite of polypropylene sutures for the closure of columellar skin
incisions. They found that both the materials produced similar cosmetic results.
However, post-operative care is simplified in case of incisions closed with butyl 2-
cyanoacrylate as its forms its own protective barrier around the incisions.

Rosin D, Rosenthal R.J, Kuriansky et al (2001) closed more than 250 trocar site
wounds using N-butyl-2-cyanoacrylatetissue adhesive. They found that glue
 15

application is quick and easy with extremely low infection rate and provided
excellent cosmetic results. They concluded that tissue adhesive is a viable option
for laparoscopic wound closure.

Comparison of N-butyl-2-cyanoacrylate tissue adhesive with sutures in 50 patients

who underwent a variety of hand operations were studied by Sinha S, Naik M,
Wright V et al (2001). They concluded that tissue adhesive is as effective as suture
in terms of wound infection and dehiscence.

Sudeer Krishna (2002) used Isoamyl-2-cyanoacrylate tissue adhesive in 25 patients

for the closure of incisions placed in extraoral maxillofacial region and concluded
that it can be used as a reliable and safe method for small tension free facial
incisions.

Al-Belasy and Amer M.Z. (2003) studied the local hemostatic effect of N-butyl-2-
cyanoacrylate tissue adhesive in 30 warferin-treated patients who underwent
outpatient oral surgical procedures without a change in their level of
anticoagulation. They concluded that N-butyl-2-cyanoacrylatecan be used as an
effective local hemostatic agent in oral surgical procedures.
 16

Chapter: two

Materials and methods

 17

MATERIALS AND METHODS

Type of study: Non-randomized non-blinding controlled clinical study.

Place of study: Department of Oral and Maxillofacial Surgery,

Dhaka Dental College Hospital

Period of study: July, 2011 to June, 2012.

Study population: Patients who attended the Indoor clinic of the Department of
Oral and Maxillofacial Surgery, Dhaka Dental College Hospital, Dhaka for various
surgical procedures with extra oral incision under general anaesthesia were
selected.

Source of the materials: Butyl cyanoacrylate is obtainable in sealed sterile

containers as ampoules of 0.25 ml to 1.0 ml. This study was done with “NectacrylTM”
of 0.25 ml ampoule marketed by Dr. Reddy’s laboratories limited. The other
material ProleneTM, a non-absorbable polypropylene suture was marketed by
Ethicon, a division of Jhonson and Jhonson Company.

Sampling method: Convenient sampling

Sample Size: Sixty patients who attended the Department of Oral and Maxillofacial
Surgery, Dhaka Dental College Hospital, Dhaka for various surgical procedures
were selected. Among the sixty patients, thirty patients were grouped into Group-A
for application of 4/0 polypropylene suture materials and the remaining were
selected for Group-B for application of tissue adhesives

STUDY DESIGN

This study was a comparative study in between tissue adhesives and polypropylene
suture materials to observe the healing efficacy of these closure materials. Sixty
patients who attended the Department of Oral and Maxillofacial Surgery, Dhaka
 18

Dental College Hospital, Dhaka for various surgical procedures were selected.
Among these patients, thirty were grouped into Group-A, for application of 4/0
polypropylene suture materials and the remaining were in Group-B for application of
tissue adhesives. The lengths of the incision were selected below the 20 c.m. in
each group. Wounds were evaluated on first and seventh post-operative day for
external bleeding, pain, wound dehiscence and wound infection. Wounds were
again reevaluated eighth post-operative week for initial scar formation and
satisfaction of the patient.

SELECTION OF CASES

Patients who were attended the Department of Oral and Maxillofacial Surgery,
Dhaka Dental College Hospital, Dhaka for various surgical procedures under
general anesthesia were selected. The selections were based on certain inclusion
and exclusion criteria:

Inclusion criteria:
 The patients in good general health with no significant systemic
abnormalities.
 Only clean incisions were included.
 Incision with low tension following the closure of subdermal layers.
 Patients from both the groups having approximately similar lengths
of incision are to be segregated for the study.
 Those who will be fulfilled and consented for the study and agreed to
return for follow up are to be enrolled for the study.

Exclusion criteria:
 Non-cooperative patient.
 Patient who refused to attend regular follow up.
 Patients with a known history of skin disease, vascular diseases
/collagen diseases and clotting disorders
 Patients with a history of keloid formation and hypertrophic scars.
 Patients with known history of allergy to the formaldehyde and
cyanoacrylate adhesive material are also excluded from the study.
 19

A detailed clinical history for each sample was taken. Routine necessary
hematological and other investigations were done. The selected patients were
informed of procedure of surgery, method of closure of surgical wound, their
advantages and complications.

MATERIALS

Polypropylene suture material

Prolene is a synthetic, monofilament, nonabsorbable polypropylene suture. It is

indicated for skin closure and general soft tissue approximation and ligation. Its
advantages include minimal tissue reactivity and durability. Disadvantages include
fragility, high plasticity, high expense, and difficulty of use compared to standard
nylon sutures.4/0 Prolene were available from Ethicon and were used in this study.
Polymer polypropylene (Prolene) appears to be stronger then nylon and has better
overall wound security. However, it has a greater memory (returns to its packaging
shape) and is more difficult to work with.

Prolene commonly is used in both human and veterinary medicine for skin closure.
In human medicine it is used in cardiovascular, ophthalmic and neurological
procedures. Prolene is first manufactured by Ethicon Inc., a subsidiary of Johnson
and Johnson. The name Prolene is a trademark of Ethicon Inc.

Prolene has also become the mainstay of vascular anastomoses and had facilitated
significant advances in cardiac and vascular surgery. It is used on both small
vessels such as coronary artery bypasses and large vessels including the aorta. It
is used in obstetrical practice, during cesarean sections to suture the rectus sheath
of the abdominal wall because it is non-absorbable in nature and provides the
sheath the due strength it deserves (rectus sheath is composed of various tendon
extensions and muscle fibers and maintains the strength of the abdominal wall, if it
becomes weak the abdominal contents start herniating out) it stays there forever
and is also often seen during repeat cesarean section as that of the previous
section. A polypropylene mesh is also used for repairing hernias and other injuries
to the fascia.
 20

Synthesis of polypropylene suture material:

Propylene was first polymerized to a crystalline isotactic polymer by Giulio Natta as

well as by the German chemist Karl Rehn in March 1954. This pioneering discovery
led to large-scale commercial production of isotactic polypropylene by the Italian
firm Montecatini from 1957 onwards. Syndiotactic polypropylene was also first
synthesized by Italian Nobel Prize winner Giulio Natta and his coworkers.
Composed of an isotactic crystalline stereoisomer of polypropylene, Prolene
sutures are intended to be durable and long lasting. They are dyed blue, allowing
for easy visibility against skin and when operating. It is composed of a single
filament.

Structure of polypropylene suture material:

Surgical suture composed of an isotactic crystalline stereoisomer of polypropylene,

a synthetic linear polyolefin. The molecular formula is (C3H6) n.

Fig. 1.1 3D ball and stick model of polypropylene material, where carbon atoms
are represented with red ball and hydrogen atoms with blue balls.
 21

Biocompatibility of polypropylene suture material:

Prolene suture elicits a minimal initial inflammatory reaction in tissues which is

followed by gradual encapsulation of the suture by fibrous connective tissue.
Prolene suture is not absorbed nor is it subjected to degradation or weakening by
the action of tissue enzymes. Due to its relative biological inertness it is
recommended for use where the least possible suture reaction is desired. As a
mono – filament it has been successfully employed in surgical wound which
subsequently become infected or contaminated where it can minimize later sinus
formation and suture extrusion. Its lack of adherence to tissue Prolene is effective
as a pull out suture.

N-butyl-2-cyanoacrylate

Cyanoacrylate tissue adhesives were discovered by Coover and others in 1959.

Their general formula is CH2=C (CN)-COOR. N-butyl-2-cyanoacrylate is available
from Dr. Reddy’s laboratory as 0.25 ampoules were used in this study.

A number of studies were conducted on animals and it was found that

cyanoacrylates are organic molecules, on application bond to living tissues. Though
they are not ideal in clinical application, they can play an important role in wound
closure and hemostasis.

The theory of adhesive action is that the alkyl -2-cyanoacrylates undergo an

exothermic polymerization catalyzed by the presence of small quantities of small
base such as water. This anionic polymerization is thought to provide the bonding
action. Spreading the monomer in a thin film undergo an exothermic polymerization
catalyzed by the presence of small quantities of weak base such as water. This
anionic polymerization is thought to provide the bonding action. Spreading the
monomer in a thin film increases the adhesiveness.
There are two theories on the mechanism of adhesion of the polymer to the
tissue. It is either mechanical or chemical linkage to the tissue in which the proteins
 22

of the tissue take part. The adhesion and the elasticity decrease with the thickness
of the film of cyanoacrylate.
It became apparent after many experimental studies that the longer chain
cyanoacrylate derivatives were less toxic. Longer chains degrade at a slower rate,
thereby permitting the degradation products to be more safely metabolized and
eliciting less intense inflammatory response. The degradation products of the
polymer are Formaldehyde and Cyanoacrylate. The minimal toxicity observed with
Butyl and Iso-amyl polymer is due to low concentration of the degradation products.

Synthesis of cyanoacrylates

Cyanoacrylates are synthesized by reacting Formaldehyde with alkyl cyanoacrylate

to obtain a polymer, then depolymerizing the material by heating to distill of the
liquid monomer. The general formula of cyanoacrylates is CH2=C (CN)-COOR. It is
possible to prepare different cyanoacrylates by altering the alkoxycarbonyl (-COOR)
of the molecule. The reaction is as follows:

Fig. 1.2 Reaction dictating synthesis of cyanoacrylate

 23

Mechanism of anionic polymerization of cyanoacrylate tissue adhesive involving the

ethylene bond of the cyanoacrylate monomer is polarized due to the electron
withdrawing capacity of the nitrile and alkoxylcarbonyl groups. A weak base, such
as water from tissue fluid, can initiate and complete the anionic polymerization
process.

Structure of n-butyl 2-cyanoacrylate

Fig. 1.3 Butyl-cyanoacrylate 3D-balls and stick model. Black balls representing
carbon atom, red ball representing oxygen molecule, blue balls representing
nitrogen atom and the remaining white balls representing hydrogen atom.

Biodegradability of n-butyl-2 cyanoacrylate

An adhesive has to be replaced by the body’s own tissue and should not serve as a
barrier to healing. Biodegradability is desirable as long as it is slow enough to allow
healing and the breakdown products that can be safely metabolized. The theory of
mechanism of breakdown is based on hydrolytic attack of the carbon-carbon bond
to produce Formaldehyde and resulting chain cleavage. As Butyl cyanoacrylates
have four alkyl group side chains, its biological degradation is slower than the
adhesives with shorter side chains. This slow degradation makes these materials
less histotoxic. Since they break down slowly it is not advisable to place a
 24

continuous layer between two healing surfaces. The two surfaces should be
approximated and held in everted position and the adhesives are applied over the
junction.

ARMAMENTARIUM

 Scale
 Watch
 Disposable syringes with needles.
 Surgical scalpel.
 Tweezers.
 Scissors.
 Needle holder.
 Adson tissue forceps.
 Straight mosquito forceps.
 Dry gauges.
 Straight probes.
 Skin hooks.
 3-0 round body Vicryl suture.

METHODS

Operational definitions:

 Patients undergoing extra oral incision for various surgical procedures of

head and neck region are to be selected for the study.
 Incision lengths included for the study less than 20 cm. for both group.
 Subdermal closures of this study means layer closures of surgical wound
except skin with 3-0 round body Vicryl.
 Cyanoacrylate tissue adhesive means single use n-butyl-2-cyanoacrylate
tissue adhesive supplied in a sealed sterile ampoule for superficial use.
 25

 Polypropylene/Prolene suture means 4-0 monofilament polypropylene blue

with cutting body needle.
 In Group 1 the incisions will be closed with 4-0 Prolene cutting body by
simple interrupted suturing technique.
 In Group 2 skin edges will be closed with n-butyl-2-cyanoacrylate tissue
adhesive.
 External bleeding defined as escape of blood along the wound in direct
observation, evidence in protective dressing or presence of clot in post-
operative observations.
 Pain defined in this study as unpleasant sensation.
 Wound dehiscence defined as surgical complication in which a wound
breaks and or opens along the length of surgical suture/adhesive.
 Wound infection may be defined here as the invasion of body tissues by
disease-causing microorganisms, their multiplication and the reaction of
body tissues to these microorganisms and the toxins that they produce.

Surgical procedure

Group A
After completing surgical procedure, careful subcutaneous closure was done with 3-
0 vicryl. Then the skin incisions were closed with 4-0 Prolene with cutting body
needle by simple interrupted suturing technique making sure that the skin edges
were in close approximation to each other during the closure. Following the
completion of suturing, an antiseptic medicated cream (Neobactin ointment) was
applied followed by a protective dressing. The length of the incision and the time
required to close the wound were recorded. The sutures removed after an interval
of 7 days.

The healing of the wound was observed on the first and seventh postoperative day
for external bleeding, pain, wound dehiscence and wound infection. The wound was
again follow up for initial scar formation and satisfaction of the patient at the eight
post-operative weeks.
 26

Group B

After careful subcutaneous closure with 3-0 vicryl, the skin edges were
approximated and maintained in this position either with skin hooks, Adson forceps
or manually with fingers. The adhesive will then be applied along the edges of the
incision in thin film with insulin syringe or dropper with needle supplied with the
adhesive pack. All the time, taking care that the adhesive were not flowed between
the skin edges. It may take 5 to 30 seconds to dry but at least 5 minutes should wait
for the cyanoacrylate polymer to dry completely. The length of the incision and the
time required to close the wound was recorded. Application of any sort of
medication or associated dressing will not require since the adhesive being a water
proof, bacteriostatic and hemostatic agent acts as a private dressing. The adhesive
material need not to be removed and would fall automatically after re-
epithelialization.

The healing was observed on the first and seventh postoperative day for
external bleeding, pain, wound dehiscence and wound infection. The wound was
again follow up for initial scar formation and satisfaction of the patient at the eight
post-operative weeks.

Variable:
The following variables were considered in all subjects.
1. Length of incision
2. Wound closing time
3. External bleeding
4. Pain
5. Wound dehiscence
6. Wound infection
7. Initial scar formation
8. Satisfaction of the patient
 27

Data collection technique:

A standardized structured data collection/observation sheet (Appendix-B) was used
to collect necessary information of the subject group. Data sheet included all of the
variables regarding to the study.

Data analysis:
Data were screened and cleaned for any discrepancy. After cleaning data were
entered in to template of SPSS@17 software. Demographic and baseline
characteristics were compared with the use of chi-square test for categorical
variables and analysis of variance acceptance test for continuous variables.
Descriptive statistics were generated to see the distribution of baseline
characteristics of the patient. A two-sided p<0.05 level of significance was selected
for all analysis.

Consent from the patients:

An informed written consent will be taken for every patient explaining the
nature and objectives of the study.
 28

Chapter: three

Results
 29

RESULTS

A total number of 60 cases were studied to compare the healing of incisions using
Prolene and N-butyl-2-cyanoacrylate in various extra oral maxillofacial surgical
procedures. This study was done to compare the healing and cosmetic outcome of
head and neck surgical incision and finally to evaluate the efficacy of n-butyl-2-
cyanoacrylate as a wound closure material in comparison to polypropylene suture.

In total 60 patients 11 types of incisions were recorded. Submandibular incisions

were mainly (25%) used followed by Preauricular incisions (Popwitch modification)
(13.3%). The length (mean±SD) of the incision was 11.60±5.63 and 8.20±4.11 cm
in Group-A and Group-B respectively. The wound closing time for Polypropylene
material for a mean 11.60 cm incision was 31.36 minute whereas the N-butyl-2-
cyanoacrylate tissue adhesive needed 19.76 minutes in a mean 8.20 cm. incision.
Overall post-operative complications were 41.75% in Group-A and 18.89% in
Group-B. There was no observable wound infection and wound dehiscence in first
post-operative day in both groups.86.7% of incisional scar were aesthetically
acceptable by patients in Group-B and in Group-A 70% scar marks were
aesthetically acceptable. In general patients satisfaction over the incisional wound
was 76.7% in Group-A and 90% in group-B.

The findings obtained from data analyses are presented here.

 30

3.1 Age distribution:

Figure 1.4 demonstrates highest percentage (36.7%) of the total subject from both
group was from the age group 11-20 years and the lowest (5%) from the age group
over 50 years. There was no subject in Group-A (Prolene) below the age of 10
years.

Fig. 1.4 Age distribution of the patients (n=60) in both groups

 31

3.2 Sex distribution:

Figure 1.5 demonstrates the sex distribution of the subjects. In this study among 60
patients male were 31 (51.7%) and female were 29 (48.3%).

Fig. 1.5 Distribution of the patients by sex

 32

3.3 Name of the surgical incision:

Figure 1.6 descries the distribution of the surgical incisions in the subjects.
Submandibular (Unilateral) incisions were maximally (Total= 15, 25%) applied in
both groups followed by Preauricular (Popwitch modification) incisions (Total= 8,
13.3%) in Group-B only. Total 11 types of incisions were used in this study.

Fig. 1.6 Distribution of the surgical incisions

 33

3.4 Frequency of incision associated with length

In total 60 patients 11 types of incisions were recorded. Submandibular incisions

were mainly (25%) used followed by Preauricular incisions (Popwitch modification)
(13.3%). The length (mean±SD) of the incision was 11.60±5.63 and 8.20±4.11 cm
in Group-A and Group-B respectively.

Table 3.1 Mean distribution of various Incisional lengths (in cm)

Incision n Mean SD Minimum Maximum

Submandibular-unilateral 15 13.33 2.66 9.00 19.00

Risdon 8 6.00 2.26 4.00 9.00

Weber-Ferguson 5 17.40 0.54 17.00 18.00

Preauricular 6 6.00 0.63 5.00 7.00

Preauricular-Popwitch variety 8 12.00 2.97 5.00 14.00

Post-ramal 5 5.80 1.78 4.00 8.00

Infraorbital 5 3.40 0.54 3.00 4.00

Lateral Eyebrow 4 3.50 1.00 3.00 5.00

Extended SM 1 16.00 0.00 16.00 16.00

Bilateral-SM 2 16.00 2.82 14.00 18.00

Lip split with SM 1 19.00 0.00 19.00 19.00

Total 60 9.90 5.18 3.00 19.00

n : Number of subject
cm : Centimeter
SD : Standard Deviation
SM : Submandibular

p=0.000 which was significant in Analysis of variance assessment test

 34

3.5 Wound closing time associated with length of incision

The length (mean±SD) of the incision was 11.60±5.63 and 8.20±4.11 cm in Group-
A and Group-B respectively. The mean wound closing time for Polypropylene
material was 31.36 minute whereas the tissue adhesive needed 19.76 minutes.
Both of these parameters were statistically highly significant which were p=.010 in
Group-A and p=.000 in Group-B in unpaired t test.

Table 3.2 Wound closing time associated with length of incision

Length of incision Wound closing time

in centimeters in minutes

(mean ± SD) (mean ± SD )

Group-A 11.60 ± 5.63 31.36 ± 14.04

Group-B 08.20 ± 4.11 19.76 ± 9.45

Probability p=.010(S) p=.000(S)

SD : Standard Deviation

S : Significant in unpaired t test of significance of difference

 35

3.6.1 Comparison of Post-operative complication

Overall post-operative complications were 41.75% in Group-A and 18.89% in

Group-B. External bleeding was more common in first post-operative day in Group-
A (77.3%) and much less in Group-B (16.7%). There were no sign of external
bleeding in first post-operative week in Group-B whereas Group-A shows
13.3%.Both of these data related with the observations of external bleeding were
highly significant (p=0.00 and p=0.05 respectively in first post-operative day and
week) in chi-square test. In terms of pain perception, Group-A showed 90% and
43.3% and Group–B figured 70% and 20.0% respectively in first post-operative day
and first post-operative week.

Table 3.3 Post-operative complication on external bleeding and pain

EB EB Pain Pain

1st POD (%) 1st POW (%) 1st POD (%) 1st POW (%)

Present Absent Present Absent Present Absent Present Absent

Group-A 77.3 26.7 13.3 86.7 90 10 43.3 56.7

Group-B 16.7 83.3 0.00 100 70 30 20 80

p-value p=0.00(S) p=0.05(S) p=0.05(S) p=0.04(S)

EB : External Bleeding

POD : Post-operative day

POW : Post-operative week

S : Significant in chi-square test

NS : Not Significant in chi-square test

 36

3.6.2 Comparison of Post-operative complication and healing

There were no sign of wound infection in first post-operative day both in Group-A
and Group-B. Both the wound infection and wound dehiscence rate in first post-
operative week shows 13.3% and 3.30% in Group-A and Group-B respectively.
These data was not statistically significant (p=0.117) in chi-square test.

Table 3.4 Complication compare over wound infection and dehiscence (n=60)

WI WI WD WD

1st POD (%) 1st POW (%) 1st POD (%) 1st POW (%)

Group Present Absent Present Absent Present Absent Present Absent

Group-A 0.00 100 13.3 86.7 0.00 100 13.3 86.7

Group-B 0.00 100 3.30 96.7 0.00 100 3.30 96.7

p-value - p=0.117(NS) - p=0.117(NS)

n : Number of incision

WI : Wound infection

WD : Wound Dehiscence

POD : Post-Operative Day

POW : Post-Operative Week

NS : Not significant in chi-square test

 37

3.6.3 Figuring the initial cosmetic outcome in both groups

86.7% of incisional scar were aesthetically acceptable by patients in Group-B and in

Group-A 70% scar marks were aesthetically acceptable. General patients
satisfaction over the incisional wound was 90% in Group-B and 76.7% in group-A.
However both of these data failed to prove any statistical significance (p=0.105 and
p=0.149 respectively in initial scar formation and satisfaction over incisional wound.

Table 3.5 Comparison of initial cosmetic outcome at 8th POW (n=60)

Initial scar formation of the wound Satisfaction of the patient

AA (%) AU (%) Satisfied (%) Not satisfied (%)

Group-A 70 30 76.7 23.3

Group-B 86.7 13.3 90 10

p-value p=0.105(NS) p=0.149(NS)

n : Number of incision
POW : Post-operative week
AA : Aesthetically Acceptable
AU : Aesthetically Unacceptable
NS : Not significant
 38

Chapter: Four
Discussion
 39

DISCUSSION

Early, uncomplicated wound healing has been a subject of intensive research over
the ages. The complexities involved in wound healing, such as involvement of more
than one type of tissue, various degrees of wound strength during the process of
healing, exposure of the biomaterials to body fluids and a variety of wounds, each
with its own healing problems, call for different types of wound closure materials
(Key 1995)

In general, wound closure biomaterials are divided into three major categories:
suture materials, staples and tissue adhesives. Suturing has been the most widely
used method for wound closure because of high reliability of suture materials.
However, alternative techniques have long been sought, since suturing technique
requires skill and experience, a relatively longer time and the need for its removal.
Due to these reasons, surgeons are increasingly using tissue adhesives over
sutures for wound closure (Morikawa 2001). Several studies regarding the use of
the tissue adhesives in closure of facial wounds have been conducted to compare
their efficacy against the conventional sutures (Singer 2008 and Quinn 1993).

Although most facial wounds heal without complications, owing to the abundant
blood supply of the region, mismanagement may result in infection, wound
dehiscence, and unsightly and dysfunctional scar (Toriumi 1998). Cyanoacrylate-
based adhesive systems are most recent tissue adhesives. The rapid setting time
and desirable effect of moisture on polymerization have made them most
investigated system.

N-butyl-2-cyanoacrylate (Nectacryl) is a recent cyanoacrylate derivative with eight

alkyl constituents off the carboxyl group, which slows down the degradation and by-
product release into the surrounding tissues. Additionally, plasticizers have been
added which make the adhesive bond stronger and more durable but allow flexion
of the skin. Its usage as a skin adhesive was first described by Quinn (1997) and
Toriumi (1998).
 40

Cyanoacrylates have a number of advantages over conventional sutures, like their

fast and painless application, rapid setting which reduces the total operating time,
their antibacterial properties. Cyanoacrylate itself acts as a water proof dressing
and helps in reduction in the number of follow-up visits. As they do not require any
needles, accidental needle stick injuries are prevented. However, there are certain
disadvantages of cyanoacrylates like their less tensile strength and chances of
adhesive seepage if edges are not properly approximated.

Only a limited study have shown equivalence of N-butyl-2-cyanoacrylate to skin

sutures in esthetic facial surgery and repair of traumatic facial wounds (Chu 1981).
However, it is important to remember that dermal suture support is still needed (in
wounds that traverse the full thickness) and skin must be held together as the
adhesive is applied to prevent the deposition of the cyanoacrylate polymer into the
wound, potentially delaying or preventing the healing.
Cyanoacrylate tissue adhesives were first developed in 1940’s. In the year 1959
Coover et al used the first adhesive Methyl-2-cyanoacrylate as a surgical adhesive.
They found it to be tissue toxic. Later various types of cyanoacrylates were
developed. But clinical trials revealed that they were also toxic to tissue (Adoni
1981).

The present study is an attempt to compare clinically, the healing of incisions by

using N-butyl-2-cyanoacrylateand Isoamyl 2-cyanoacrylate tissue adhesives.

Effective wound healing can be obtained by following certain principles.

 Use of small amount of tissue adhesive

 Rapid approximation of the tissue edges whiles the adhesive still in its liquid
state.
 Applying light pressure to tissue edges and holding them in place for at least
10 seconds (Burns 1996).
 41

To our knowledge, this is the first study that has analyzed the efficacy of N-butyl-2-
cyanoacrylate tissue adhesive as a skin closure material in different surgical
incision in maxillofacial arena in our country.

The results of our study clearly demonstrate that N-butyl-2-cyanoacrylate tissue

adhesive is used effectively as a head and neck skin closure material in different
surgical incision. The efficacy of this newer material was compared with the most
common conventional suture material, Polypropylene suture. Furthermore N-butyl-
2-cyanoacrylate can be a better alternative to the Prolene in the means of wound
closing time, post-operative complication and as well as cosmesis in maxillofacial
area.

In terms of time needed to close the wound, it was persistently seen that N-butyl-2-
cyanoacrylate required less time in comparison with the Polypropylene suture. The
longer the length of the incision the greater the time difference was seen. Dalvi
(1986) conducted cyanoacrylate skin closure in 30 cases reflect this result. Quinn et
al (1993) and Toriumi et al (1998) both found the time required for closure with
cyanoacrylate adhesive was one-third of the time required for suture closure.

Overall post-operative complications were 41.75% in Group-A and 18.89% in

Group-B. External bleeding was more common in first post-operative day in Group-
A (77.3%) and much less in Group-B (16.7%). There were no sign of external
bleeding in first post-operative week in Group-B whereas Group-A shows
13.3%.Both of these data related with the observations of external bleeding were
highly significant (p=0.00 and p=0.05 respectively in first post-operative day and
week) in chi-square test. This study reflects that, the N-butyl -2-cyanoacrylate has
got the property of haemostasis and also acts as occlusive dressing.

Pain perception in both follow-up (First and seventh post-operative day)) setting is
more or less equal in both groups. There was no significant difference in both
clinically and statistically. This result is different from Knott (2007), who found better
pain perception in cyanoacrylate group. This is may be due to the dressing applied
over some subject of cyanoacrylate group.
 42

Qureshi A et al (1997) reported on the bacteriostatic effect of cyanoacrylates.

Bhaskar et al (1969) stated that Butyl cyanoacrylate was phagocytosed locally
produced minimal tissue necrosis and abscess formation. Annabelle (2001)
observed that there was no incidence of wound infection of wound infection in any
of his cases with both N-butyl-2-cyanoacrylateand Isoamyl 2-cyanoacrylate tissue
adhesives. Rosin et al (2001) reported a case of wound infection with N-Butyl 2-
cyanaocrylate and Isoamyl 2-cyanoacrylate and he relates it to the improper
approximation of the wound edges.

In the present study, it is noticed that there was no wound infection or dehiscence in
first post-operative day visit. However in the follow-up at 7th post-operative day N-
butyl-2-cyanoacrylate shows less (3.3%) wound infection than Prolene (13.3%).
Wound infection had been shown to be more in suture technique. Suture provides
an extra source of contamination via suture canal, perisutural cuff of dead
epidermis and subcutaneous fat. It provides all the factors necessary to initiate
wound infection.

Carpendale and Sereda (1965), in their studies, showed that wound infection is
higher with suture material as compared to use of adhesive.

Higher cyanoacrylates like N-butyl-2-cyanoacrylate degrade at a slower rate than

those with shorter side chained ones. These materials are less histotoxic due to
their slow degradation (Blum et al 1975). As they breakdown slowly it is not
advisable to apply a continuous layer between two tissue surfaces. The tissue
edges should be approximated before the adhesive is applied over the junction
(Burns et al 1998). When the edges are improperly approximated, adhesive
material may enter into the wound thereby interfering with edge approximation
leading to wound dehiscence.

Many studies reported the incidence of wound dehiscence with N-Butyl 2-

cyanoacrylate. Qureshi et al (1997) reported 2 of 102 cases of partial dehiscence
after general and laparoscopic surgeries and he related its occurrence to the
inadequate drying of the skin edges before the skin edges before the application of
adhesive.
 43

Sudder Krishna (2002) used Isoamyl 2-cyanoacrylate for closing extra oral incisions
placed in maxillofacial region and reported very few cases of wound dehiscence.
He stated that wound dehiscence might be due to the pre-existing edema present
at the surgical site.

Our study showed wound dehiscence single cases of N-butyl-2-cyanoacrylate and

4 cases of Polypropylene suture in first post-operative week follow up.

Last postoperative evaluation was done at the end of second month (8th post-
operative week) for cosmesis and satisfaction. Scar was evaluated for patient’s
acceptance and satisfaction in nominal scale. Though the study showed clinically
better acceptability and satisfaction on N-butyl-2-cyanoacrylate adhesive over
Prolene, but the difference in cosmetic outcome in between both the groups was
statistically insignificant (p=0.105 and p=0.149 respectively). Similar results were
found in several other prior studies by Quinn (1997), Toriumi (2002) and Singer et
al (2008). However a study by Bernard et al (2001) showed a statistically significant
difference in favor of sutures.

From this study it would appear that results obtained might match with the studies
of Shivmurthy et al (2009) and Dalvi et al (1986).

The results of this preliminary study indicate that N-butyl-2-cyanoacrylate tissue

adhesive can be used effectively, safely and as a reliable method for closure of
facial incisions in preference to Polypropylene suture.
 44

Limitations of the study

The present study suffered the following limitation and should be kept in mind while
deciding on the implications of the findings of the study

1. This was a single hospital based descriptive study located in the capital city
which may not be representative of the whole population.

2. The duration and sample size was small.

3. Patients were not randomized with the given option to choose the method of
skin closure.

4. This was a non-blinding study so there was biasness.

5. Relative unavailability of the N-butyl-2-cyanoacrylate tissue adhesive and

lack of proper funding which did not allow expensive investigations.
 45

Conclusion and recommendation

The present study was done to evaluate the efficacy of N-butyl-2-cyanoacrylate

tissue adhesive as an external wound closing material comparing with
polypropylene suture material in head and neck region.

60 cases were selected for the study and divide into two equal groups. The length
of the incisions varied from 2 to 19 cm. The length of individual incision and their
closing time was recorded in each case per-operatively. These wounds were
evaluated on first and seventh day for external bleeding, pain, wound infection and
dehiscence. The cosmetic outcome was measured with initial scar formation and
satisfaction of the patient was marked at 8th post-operative week visit.

Based on the present study, N-butyl-2-cyanoacrylate tissue adhesive, though

statistically not significant always (P>0.05), gave better results and hence can be
used effectively, safely and as a reliable method for closing incisions in maxillofacial
regions in preference to Polypropylene suture. We may conclude that the use of N-
butyl-2-cyanoacrylate is better than sutures in closure of surgical incisions in head
and neck region.

However further studies with larger sample size on our population should be
conducted to compare its performance and possible side effects before general use
can be recommended.
 46

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 47

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